Proceedings of the Subcommittee on
Veterans Affairs
Issue No. 21 - Evidence - October 31, 2018
OTTAWA, Wednesday, October 31, 2018
The Subcommittee on Veterans Affairs met this day at 12:01 p.m. to continue its study on the services and benefits provided to members of the Canadian Forces; to veterans; to members and former members of the Royal Canadian Mounted Police and their families (topic: study on cannabis use for medical purposes by Canadian veterans).
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Mark Palmer, Clerk of the Subcommittee: As clerk of this subcommittee, it is my duty to inform you of the unavoidable absence of the chair and deputy chair and to preside over the election of an acting chair.
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I am ready to receive a motion to that effect.
Senator McIntyre: I propose Senator Boniface.
Mr. Palmer: It is moved by the Honourable Senator McIntyre that the Honourable Senator Boniface do take the chair of this committee.
Is it your pleasure, honourable senators, to adopt the motion?
Hon. Senators: Agreed.
Senator Gwen Boniface (Acting Chair) in the chair.
The Acting Chair: Thank you for your confidence to chair’s today’s meeting in the absence of Senator Dagenais.
Today, we continue our look at cannabis use for medical purposes by Canadian veterans. We welcome, from Canada House Clinics, Alex Kroon, President; and Riley McGee, President, Abba Medix.
Gentlemen, you have the floor, and then we’ll follow with questions from senators.
Alex Kroon, President, Canada House Clinics: Thank you very much, Madam Chair and honourable senators, for the opportunity to speak regarding medical cannabis for veterans and first responders. I am the President of Canada House Clinics, which was, until recently, known as Marijuana for Trauma. We were founded in 2013 by veterans who discovered that medical cannabis transformed their lives after years of struggling with conventional pharmaceutical treatment of combat PTSD.
This is a joint statement with Riley McGee, who himself is a veteran and who, as a combat engineer, suffered from PTSD. He currently is president of our sister division, Abba Medix, a licensed producer of medical cannabis, and previously ran our clinics.
We currently provide active cannabinoid therapy to over 5,100 Canadians, including over 2,300 veterans. We have over 12,000 patients in our database.
Cannabinoid therapy is a very powerful part of a larger treatment — coping skill and reintegration plan — for veterans to rebuild their lives after both PTSD and the difficult transition to civilian life. Our veterans report that cannabis better manages their symptoms and quality of life than pharmaceutical treatments, and decreases dependence on unhealthy coping tactics.
We support increased research into cannabis, our endocannabinoid system and why cannabis works. We commend Veteran Affairs Canada for taking a global leadership position in providing paid access for medical cannabis, and I am proud that our company and its founders were part of the activist movement to encourage that.
The committee has heard a variety of opinions. It’s almost like cannabis and PTSD are not simple. Cannabis is definitely not simple. To be used properly as medicine requires expert guidance. A certain cannabinoid profile of a particular strain can be very effective in dealing with anxiety. A different profile of a different strain can make anxiety much worse. If you study a group of people who are being expertly treated with cannabinoid therapy, we are confident the research will reflect the positive outcomes we see every day. If you select inappropriate cannabinoid profiles and treatment protocols for a particular condition, the results will be negative.
When you look at the number of strains, active ingredient profiles (cannabinoids, terpenes, flavonoids), dosage levels and methods of usage, there are millions of permutations with distinct medical outcomes. Health Canada lists over 30 potential therapeutic uses for cannabis.
Traditional pharmaceutical clinical study approach is to study one chemical molecule for one condition prior to getting real world experience. Applying that pure approach to cannabis would take hundreds of billions of dollars and over 100 years, and really ignore the entourage effect. We need to take a new, blended research approach to professionally leverage the real-life experiences of thousands of regular users — scientists working with industry cannabinoid educators reviewing patient data.
Our next version of the software platform will download the detailed compound profile of each strain being used and allow us to combine that with real patient ongoing clinical data.
Medical cannabis has been legal for 17 years. Humans have used it for thousands of years. Compared to many drugs, it is safe, has not been fatal in overdose and, at minimum, helps people sleep better, manage moods and cope with inflammation. Side effects can be managed and it has a lower rate of addiction with smaller withdrawal effects. It is an exit medicine, not a gateway drug. Many medical users take CBD, which does not have a psychotropic effect. With legalization, there is a growing acceptance that can facilitate better research. Cannabis is not a silver bullet or a cure-all; it is a natural multipurpose medication that is particularly effective for people with multiple conditions.
We cannot ignore what our veterans, and their spouses and partners tell us. When a crying wife drops off her husband at our clinic, pleading that, after two years of conventional treatment, she can’t help anymore and worries about his suicidal ideation, we know traditional therapies fail many veterans. We believe in our motto, “We Help Renew Lives,” because every day we see powerful positive changes.
Beyond reducing nightmares, insomnia, pain, depression, anxiety, and reliance on alcohol and opioids, a high percentage of our veteran clients report that medical cannabis improves their lives through mood regulation to have more compassion for those they love and care for.
Veterans on traditional medications describe feeling like zombies, isolated in their basements, still clinging to unhealthy thoughts, impaired by hyper-vigilance and not able to sustain normal relations with spouses, children and friends. Only vapourization of cannabis provides the fast five-minute response to the onset of triggers that gives veterans confidence to return into society. Cannabis creates the conditions to have energy and self-reflection to work on therapy.
Since 2013 our organization and processes have evolved. We only accept physician referrals or legitimate documented diagnoses. Our nurse educators do a thorough review of clinical history. Looking at multiple factors, they recommend a patient-specific cannabinoid treatment protocol that generally involves products from multiple licensed producers and different products for day and evening. We educate our clients on how to use and we facilitate their registration with licensed producers. We use trained doctors to review and prescribe. Our nurses follow up for renewals and ongoing support to modify treatment protocols. When we sample our data, the vast majority of clients reduce use of pharmaceuticals, including use of opioids.
Canada House feels strongly about supporting veterans beyond cannabinoid therapy. We ensure veterans know about the many programs that Veterans Affairs funds. We provide space in our clinics for veterans to socialize, medicate and facilitate peer support.
At Canada House, we believe there is a gap in helping veterans beyond medication and traditional therapy. We fund a not-for-profit named the Post Traumatic Growth Association, or the PTGA, led by a trained veteran named Eric Lai. The PTGA has developed, in conjunction with a review of best practices, an eight-point holistic approach to improving the lives of veterans and first responders. Localized and veteran-led organic not-for-profits can better relate to veterans and successfully introduce strategies like music, yoga and meditation therapies, and provide life and health skills necessary to thrive outside of the military. Veteran Affairs may pay for frozen food, but if a soldier went from home to the army directly and had meals provided for eight years, who is teaching the veteran to cook and prepare healthy food?
At Canada House, we treat everyone, including seniors. Seniors share the same negative polypharmacy where one person is prescribed with over five, if not over 10, drugs. There is significant clinical evidence that polypharmacy is harmful. The original clinical studies that approved those drugs did not test the impact of polypharmacy on vulnerable patients. Seniors tell us of many years spent struggling with standard treatments and then gaining significantly better quality of life with medical cannabis. That is why 94 per cent of our staff, when we surveyed them, reported that their job is very meaningful.
We wish to provide the following recommendations to the Senate. First, continue to meet with veterans to hear their stories. We certainly can assist in facilitating meetings directly with veterans anywhere in Canada.
Second, recognize the complexity of medical cannabis and mandate the use of quality medical cannabis clinics to ensure robust assessment, education and follow-up. Neither PTSD treatment nor medical cannabis is well suited in isolation for an app or rapid prescription with limited education.
Third, there needs to be a better collaboration between medical community, researchers and experienced cannabinoid therapy educators to scientifically leverage real world data. We are open to collaboration and have started a partnership with the University of New Brunswick. Associated with that, we’d also like to mandate licensed producers to share the data, the certificate of analysis, the detailed cannabinoid profile of the strains patients are using. Again, that could be mapped to the actual clinical experience to get real evidence in terms of ongoing effects.
Fourth, there should be funding to expand veteran-led trained facilitation of holistic peer groups that address health and life skills aspects of reintegrating into life, similar to what the PTGA does.
We are watching closely, ensuring that the licensed producers continue to support the medical environment, as they’re also doing production for the recreational market.
Last, we advocate continuing to have a separate operating environment for medical cannabis with regulations that create opportunity for increased financial coverage beyond veterans for the army, civilians. Cannabis is more expensive than many pharmaceuticals, but when used appropriately improves outcomes, which helps Canadians, employers and governments. Taxation policy should encourage responsible medical cannabis use.
We want to thank veterans and first responders for their sacrifice, Veterans Affairs, researchers and all doctors who are open to exploring cannabinoid therapy. We welcome your questions today.
The Acting Chair: Shall we open it to questions then?
Senator McIntyre: Thank you, Mr. Kroon, for your presentation.
How do you think the legalization of recreational marijuana will affect veterans’ use of medical marijuana? Do you anticipate that people could self-medicate using recreational cannabis without appropriate medical follow-up? I think follow-up, bearing in mind your presentation, is extremely important.
Mr. Kroon: Absolutely. It’s a great question. We hope, and certainly will encourage all veterans to continue to go through a medical process relative to their cannabis use for PTSD or chronic pain and other conditions.
As you’ve indicated, it’s extremely important to fine-tune the treatment. Again, it’s never simply just about one strain of cannabis. There’s different usage during the day and the evening. There is some experimentation that needs to occur.
Therefore, in terms of having ongoing clinical assessments and ongoing renewals, it is very important that it continues to go through a separate medical process.
Riley, as a veteran yourself, do you have anything to add? It is extremely important that the medical process continues for veterans.
Riley McGee, President, Abba Medix, Canada House Clinics: We see the medical and the recreational as very separate. I think the service offering we have at the clinics is very conducive to what a veteran needs to heal and improve their lives with cannabis. I think that veterans will continue to seek cannabis through a clinical platform like ours.
Senator McIntyre: I have a question regarding gender issues.
Approximately what proportion of your customers are women? More specifically, what proportion of your customers who are veterans are women? Are there indications that cannabis could act differently on men and women?
Mr. Kroon: For veterans, I don’t have the specific number, but obviously it would skew more male than female. Outside of our veterans, we have slightly more Canadians we work with than veterans. Quite a few of those are seniors. Again, it’s a range of different ages depending on the conditions. But I would say, outside of veterans, it would be split fairly evenly, as the proportion of population.
Riley, do you have any further indication on that?
Mr. McGee: It’s difficult to say, without going back to our database, to give you exact numbers, which we could do. What’s important is that we validate medical patients on a software platform that helps us understand and track exactly that, to know whether it’s affecting women differently than men, what strains are tied to what conditions and improvements, and really start to understand the science behind cannabinoid therapy. It is a platform that validates the patient, gives them a recommended treatment protocol, and tracks the cannabis they’re actually using to treat what condition.
When we’re using a software platform like that, we’ll finally be able to provide the evidence that physicians, Veteran Affairs Canada and the medical community has wanted for decades. Until we can all cooperate and collaborate and bring medical patients on to this type of platform, I think that evidence will continue to elude us.
Mr. Kroon: Again, we use nurses as our cannabinoid therapy experts and they certainly look at everything in terms of the medical condition. I suspect they would be looking at gender because, similar to alcohol, there are some differences in terms of the impact on male and female. So there definitely are differences there.
They will look at elements such as if someone was a cannabis user previously recreationally, versus someone who hasn’t been. That is factored into their recommendations as well.
In our view, the key is that you have a patient-specific cannabinoid treatment plan which looks at medical history, condition, diagnosis, usage in the past, what they are doing day and evening, need to drive, need to work, and all those different elements. I think the most important element is this idea that it has to be a patient-specific treatment plan.
Senator McIntyre: I have another question regarding the impact of legalization of recreational marijuana.
Mr. McGee, I understand you’re a licensed cannabis producer?
Mr. McGee: That’s right.
Senator McIntyre: My question is about the medical market versus the legal recreational market. As you know, licensed producers, according to the media, are experiencing shortages of cannabis. As a result, patients using medical cannabis are apparently having trouble updating the product because their producers are now supplying the legal recreational marijuana.
Are cases of patients using medical cannabis who cannot resupply themselves widespread or isolated?
Mr. McGee: I’m hoping it is a temporary issue. There are certainly some producers that are focused more on the recreational market, so there will be less product available to their medical patients. With many of the other producers that are struggling with providing their medical patients with cannabis right now, I think a lot of it boils down to the CRA registrations and the excise duty tax stamps that are required, as well as the new packaging laws. A lot of licensed producers, as of October 17, had problems keeping inventory on their websites based on repackaging and applying these excise duty tax stamps.
I do expect that more medical cannabis will be coming online, and already has in a lot of cases.
Right now, we’re not getting widespread complaints about unavailability of products for our medical patients. Most of the licensed producers, as long as they can get the packaging down and the excise duty stamps right, do still have product available for their medical patients.
Mr. Kroon: I can add to that. Unfortunately, over the years, medical cannabis patients have experienced issues well before legalization in terms of supply as the industry has ramped up production. Again, that’s why working through a clinic, we often end up recommending — this has been a practice for years — having people split their script between multiple licensed producers just to hedge the bets a little bit.
There’s a lot of production that’s coming online in Canada, and, as Riley indicated, we’re hoping as we get through this adjustment that it is a short-term issue. Frankly, this is real medicine, people are very dependent on it, and it’s a significant issue if someone doesn’t have their medicine.
Mr. McGee: I do think that with the way the industry is structured right now, licensed producers are appropriately incentivized to provide product to the medical patients as they can retail directly to those patients. I do think that the revenue model supports the support of medical patients from a licensed producer perspective.
Senator McIntyre: In order to avoid any problems, do you believe that Health Canada should set quotas to require licensed producers to allocate some of their production to the medical market?
Mr. McGee: I think it’s a great idea. It’s something we have discussed before. The logistics of that could be challenging.
Licensed producers deal with things like crop losses and other challenges that perhaps traditional pharmaceutical producers would not. So mandating inventory levels and things like that could be great for the medical user, but could be challenging for licensed producers in some instances. I think if it’s something that could be done evenhandedly and fairly, it’s definitely something that should be done.
If LPs are going to commit and take on medical patients, they should commit to having the appropriate medicine for those patients on hand.
Senator McIntyre: This is one of the recommendations you would make to the federal government?
Mr. McGee: Yes.
Senator McIntyre: Mr. McGee, you’ve mentioned the excise tax.
Mr. McGee: Yes.
Senator McIntyre: This subcommittee has heard that, since recreational marijuana was legalized, the excise tax applies to all cannabis products, both recreational and medical. How has the excise tax, in effect since October 17, affected veterans who use cannabis for medical purposes?
Mr. McGee: Some of the licensed producers are covering the cost of that excise duty tax stamp and not flowing that through to veterans; other licensed producers are. In some cases, it has raised the cost of the cannabis for veterans above and beyond the $8.50 per gram covered by Veterans Affairs Canada and they have to top that up personally. Other licensed producers have absorbed that and are not forcing veterans to make those extra payments.
Personally, watching this industry unfold, I can understand the reason for putting an excise duty stamp on all product, both medical and recreational, based on the fact that, in the past few years, there is a substantial number of people who have utilized the medical market to access cannabis for recreational purposes, essentially. One of the goals of our group is to really validate the medical patient and put processes in place to ensure these are true medical patients. We don’t have to worry about that crossover.
Now that the recreational market is here, I’m hoping we can work together to define what a validated patient process is. Once we can validate those medical patients, we’re in a position to hopefully remove the excise duty tax from the medical regime where I don’t think it’s appropriate long-term, but I can understand why it was implemented out of the gate until we kind of shake things out and differentiate between these two markets.
Senator Richards: Thank you for your service, and thanks for your presentation.
How many NATO countries have medical marijuana as help for veterans? Do you know? Are Australia and New Zealand on board with this? Norway — are they on board with this? Do you know how many?
Mr. McGee: Several are looking at it and researching it. My understanding is — I could incorrect on this — that Canada is currently the only one —
Senator Richards: The only one.
Mr. McGee: — covering 100 per cent of the medical cannabis, for which we’re very grateful.
Senator Richards: That’s strange, isn’t it? I think that’s a little strange.
Mr. McGee: I think it’s forward-thinking. The results we’re getting are excellent. The rest of the world is looking at Canada —
Senator Richards: What I mean is that it’s strange that other countries haven’t come up with it.
Mr. McGee: Yes, absolutely. Sorry. I thought you were saying it was strange that we were doing it.
Senator Richards: No, not strange. No, no.
When I ask this question, people think I’m it against this, and I’m not at all. I have two friends in a hospice who use medical marijuana on a daily basis and I understand how it helps people.
But it’s not a cure-all. That’s my main question. It’s not a cure-all, and there are different strains that react with different people. I’m wondering how we can figure this out so people don’t become harmed by it if they get the wrong strain and have a psychotic event or whatever.
I’m wondering how much research goes into finding the strains that actually work for the greatest number of people. Is it a chance that you’re taking?
Mr. Kroon: Let me start, and then Riley has a lot of experience on this as well. It’s an excellent point. We feel strongly about this.
If anything, there should probably be more regulation relative to the clinic side of the industry so that you’ve only got well trained, experienced medical people who are recommending particular strains. In our case, we have 10 clinics across Canada. We’ve got years of experience. We share information among those educators that indicates what has worked for different conditions for different patients.
The most important element is that we have this database in terms of tracking what pharmaceuticals people were taking and how those pharmaceuticals change over time. Now that we are quite close to being able to have an electronic interface with licensed producers to get their certificate of analysis, which shows exactly — when people talk about a strain, it’s a bit of a misnomer, because the same strain for two different licensed producers could have a different profile in terms of the active ingredients.
Ultimately, we believe that we have to have the actual cannabinoid profile of what people are taking, marry that with ongoing patient data and experience, and then we will have a database that, over time, we can work with researchers and scientists to indicate from a real life experience perspective.
As Canada House, we want to take that leadership position in terms of ensuring we get as much data as possible. But again, we have to leverage real life experience. Unfortunately, just the nature of cannabis to try to only — the more clinical trials that could happen, that’s great, but we can’t just rely on that; we have to do a better job of managing the data out there.
But 100 per cent, people have to go through qualified cannabinoid educators and medical folks in order to get on to the right prescription. I if they don’t, then you definitely run a risk of not getting the right results.
Senator Richards: Excuse me. Just to add to that. How diverse is it? Is every plant different? Does every plant give —
Mr. McGee: There are thousands of strains and thousands of cannabinoid profiles. That’s why it’s such a difficult thing to study. We’re lucky in Canada, because we are the first country in the world to create a regulated market where the products coming out of licensed producers are lab-tested and a certificate of analysis goes with that product. Until we can connect that certificate of analysis to the medical history and the treatment protocol, we won’t be able to crack this code.
Because it’s not a single molecule pharmaceutical, you can’t be studying it in a conventional phase 3 clinical study. Essentially, you do phase 3 clinical studies to get to the phase 4 studies, which is the real world test.
This has been brought to market through Supreme Court rulings, so we don’t have the need for phase 3 clinical studies. Because it’s a multi-molecule substance, we need to study it and approach it differently. That’s why we’ve invested almost $2 million in developing a software platform that manages our clinics’ and clients’ experience, while at the same time collects this data that allows us to see trends between cannabinoid profiles, treatment protocols and particular conditions.
To answer your earlier question, I would never argue that cannabis is a cure for PTSD or other conditions. It’s no different than any other pharmaceuticals. What makes it different is that it’s better at treating multiple conditions, and it creates the appropriate mindset for veterans to heal, reintegrate themselves and repurpose themselves.
Cannabis is a much more effective treatment of PTSD and a tool for transitioning out of the military than handfuls of pharmaceuticals. When guys are in zombie-like states, they’re not being self-reflective or understanding what triggers them. They’re not able to improve their lifestyles.
Senator Richards: No, I tend to agree with that, but I think these questions have to be asked.
Mr. McGee: Absolutely. We’re glad you’re asking them.
Senator Richards: Thank you.
The Acting Chair: Before I move to second round, I want to follow up on the idea of a strain. Thank you for clarifying it. I’m trying to figure out how you establish what the absolutely best combination or best product is for a particular individual.
Mr. Kroon: It’s a couple of things. It’s years of experience and sharing those best practices. We want to have the best starting point. When antidepressants are being prescribed, they are typically starting somewhere, then experimenting. We want to have at least a starting point for which we think we have prior clinical experience that says it’s proved effective.
Quite honestly, we know that medicine works differently for different genetic makeups. The same medicine that works for me will work differently for you and vice versa. There has to be a bit of a guided journey. That’s why we have this ongoing relationship between our educators and the patients. Sometimes, they are emailing us daily, particularly in the early days, because there’s always going to be a bit of fine-tuning.
Over time, in terms of collecting this data, once we actually have a certificate of analysis and we get a little more scientific about it, that will improve the quality of our first recommendation. Right now, though, it’s a combination of using our experience, sharing resources across the company, looking at external results and then moving forward.
We talked earlier about how one strain can help with anxiety and another would make it worse. A balanced one-to-one indica in terms of talking about THC and CBD, particularly in an oil basis, will definitely help people with anxiety. If someone has a high-THC sativa — again, indica and sativa are two groupings of cannabis. Within each of those, there are lots of different strains and hybrids between the two. But a high-THC sativa could, in fact, make anxiety worse for someone.
That’s a simple example, again, on the fact that cannabis is very powerful, but if it’s not done effectively, it just isn’t appropriate.
Mr. McGee: A lot of it comes down to education and people experimenting with different types of cannabis to find what works for them isn’t a bad thing, as long as they’re educated on how to do it appropriately.
I don’t think it’s unique to cannabis. A lot of pharmaceuticals are administered that way: “Does it work? Oh, it doesn’t work, so on to the next thing.” This isn’t unique to cannabis. People need to be trained to access it safely and use it appropriately.
I always like to remind people that medical patients don’t use cannabis to get high. We use medical cannabis to feel normal and to lead sober lives.
Mr. Kroon: There’s great promise from a North American perspective. U.S. health insurers are paying for genetic testing, because they recognize it will get to the right pharmaceutical more quickly. We know how about 25 per cent of the population does not properly absorb pain medication, and that might be an early indication for not even trying; try something different, because we know that traditional opioids aren’t going to be effective for that segment of the population.
There’s great opportunity as we go further to apply that scientific thinking to cannabis as well.
The Acting Chair: One of you described it as a journey as you go through that. If I come into one of the clinics as a patient, for people who are listening in particular, can you explain what the steps are? You obviously make an assessment. Is there a regular follow-up to see whether it is working?
Mr. Kroon: Absolutely. People come to us. If they want more information or don’t understand the process of medical marijuana and medical cannabis in Canada, we explain that. Effectively they need to come to us with a physician referral or a well-documented diagnosis similar to what veterans would have through Veterans Affairs in terms of how they were assessed with PTSD and other elements. Based on that, we indicate to them what medical information we want because we want to complete a medical history and all of the drugs they are currently taking.
That is put together and patients are scheduled a half hour or 45 minutes with a nurse educator who basically reviews the clinical history and, based on that, asks a lot of questions around prior usage and different elements, recommends a particular profile, and then educates people in terms of how to use it.
Generally people are taking oils or vaping, but if you need a quick dose of medication then obviously vaping does that, but there are so many different ways you can take it.
Some people might choose, for economic reasons, to purchase dried flour and want to make their own oil. If you don’t do that appropriately, you lose the impact of the medicine. A lot of education needs to occur in terms of appropriate use of the medicine.
At that stage the file is sent to one of our prescribers, typically a physician, who meets directly with the patient, confirms the recommended treatment plan, issues that prescription, and then we work with the patients to recommend particular licensed producers, typically multiple products, daytime and evening use. We help the patient register with the appropriate licensed producers, send the prescription, which is called a medical document, up to the licensed producers, which then enables the person to go home and, as a purchaser, purchase against their prescription through a licensed producer. That material is sent to them.
Initially, we would do a three-month assessment. They would have to come back for a renewal of that prescription. As I said, we open the door and most patients take advantage of that to basically have ongoing interactions with our nurse educators, which is important to fine-tune that process.
At a high level, if that answers your question, that is the process that we do. I think it is the appropriate way of handling something like cannabis, which is not the same as a typical prescription drug.
Mr. McGee: One of the critical components of our process is the 90-day follow-up. Regardless of whether or not that is a renewal, we follow up with that patient and take another look at their pharmaceutical use and treatment, if they are continuing or discontinuing. As we do these follow-ups, we are able to build up patient years and understand what is really happening on the ground with patients.
The Acting Chair: Thank you. That is helpful.
Senator McIntyre: Gentlemen, as I understand, your organizations are part of the Canada House Wellness Group, and the group has three subsidiaries, including both your organizations.
Mr. Kroon: That is right.
Senator McIntyre: It also has another subsidiary called Knalysis Technologies Inc. I understand that is a business that develops technological tools to track the results of using medical cannabis. They are not here today. You have had contact with them?
Mr. McGee: Yes. We founded the company, and we have been, through Knalysis Technologies, for the past almost two years, developing cannabis patient management software. We currently run our clinics across the country, on version 1.0 of that software. We have almost completed version 2.0, which is a brand new program. We built an automatic program interface with the industry-leading seed-to-sale software.
As we bring in our patients and screen them with our nurses, we collect hundreds of data points. When we recommend the treatment protocol and connect them through this API with their licensed producers, and when they purchase from those licensed producers, the certificate of analysis of the product they purchased pushes back into our system. It is the first time in the history of the world that anyone has been able to connect that circuit. The Canadian regulated market has been the first place that has ever been possible.
That is one of the main reasons we are here today is to encourage you to continue the conversation with us, with regulators and Veterans Affairs Canada. Until we can get thousands of patients onto a platform like this, and it is mandated by the regulators that this happens, we will never get the evidence we need. This is the key to the puzzle. It will take us years to collect the data and truly understand it, but if we don’t start now, putting it on this platform, we push that timeline out further.
Mr. Kroon: For clarity, it is the software that our clinics use. In the short-term, I have leadership accountability for Knalysis in addition to Canada House Clinics; so all three are in some way represented today.
The market has seen value in that; so have clients. It is a global market, as cannabis, and medical cannabis particularly, grow in different parts of the world. It’s the right tool for that type of industry.
Mr. McGee: It interfaces with patients, physicians and producers, and collects that data in a useable format.
Senator McIntyre: Mr. Kroon, in your presentation, you mentioned that veterans on traditional medications are not able to sustain normal relations with spouses, children and friends. In your experience, does the use of medical cannabis by veterans increase or decrease the ability to function on a daily basis with family and friends?
Mr. Kroon: Our veterans overwhelmingly indicate that has a significant impact in terms of their ability to have useful and productive relationships, to have compassion for their spouse and their children.
There are examples where our clinicians in a particular clinic would first meet a veteran coming in who might not sustain eye contact, is really not participating in conversation, clearly seems quite withdrawn, and is quite stressed. You can tell that they are in distress. Three months later, on that renewal, they are coming in, they’re engaged, they’re happy, and they’re hugging folks within the clinic. Many veterans, and certainly spouses as well of their partners, will describe a significant change.
Again, we’re not saying that it is the cure. It creates the circumstances in which people can do the self-reflection. When you think about cognitive behaviour therapy, talk therapy and other elements, you have to be in a place where can you process that information. If you’re not sleeping, if you have nightmares — people might trigger on a number of different things, and if you can’t be able to process and think about what you need to do to move your life forward, it’s not going to be effective. It creates the conditions in which people can do the work that’s required in order to transition.
As I understand — Riley is a veteran, I’m not — that even without PTSD, it can be a difficult transition from military life, if that’s all you’ve known for many years, into civilian life. It’s a completely different world. That creates a certain amount of stress without even PTSD being involved. When you throw the two together, it’s really asking a lot.
It’s challenging for folks who are diagnosed with PTSD while they’re still serving and, quite honestly, it’s a long and difficult process, and it’s probably even worse before they actually fully leave the armed services and are then outside.
Absolutely, the overwhelming evidence in terms of the veterans that we work with is that it has a very positive impact.
Senator McIntyre: What about impairment? Do patients who consume medical cannabis manage to drive or go to work without being impaired?
Mr. McGee: The opportunity for impairment is always there, just like it is with any prescribed medication. People need to be educated if they are new to it, or if they are intoxicated they shouldn’t be behind the wheel. I would say that most medical users who have been using medically for a while and understand their dosages, absolutely, like I said earlier, they’re not using cannabis to become impaired. They’re using cannabis to feel normal.
Although the possibility is there, just like any other prescribed medication, I don’t think that impairment in medical patients is something that’s rampant or common.
Mr. Kroon: Part of the fundamental education process is people understanding if you’re vaping, the effect is four hours. If you’re taking edibles or oil, it might be eight hours. We are generally, across an entire patient base, encouraging a lower THC during the day, more CBD oriented. If they do benefit or need a higher THC, trying to do that in the evening. It is part of being responsible in terms of the medicine.
Senator McIntyre: With Veterans Affairs, the magic number appears to be 3 grams a day. Mr. Kroon, my understanding is that on your website you offer a second-level assessment.
Mr. Kroon: Correct.
Senator McIntyre: That enables veterans who wish to use more than 3 grams of cannabis per day the ability to apply to VAC for recognition of “exceptional circumstances.” Could you describe in more detail the second-level assessment that these patients undergo? What do you mean exactly by exceptional circumstances?
Mr. Kroon: Let me start and then Riley can chime in as well.
First, for clarity, we are leveraging a process that Veterans Affairs set up and we are executing it on behalf of veterans to assist them in navigating through that process. We have a very talented psychiatrist. There is a fair bit of work that we do up front in order to assess if someone is an appropriate candidate for that, because we understand some of the guidelines Veterans Affairs puts on it.
Quite honestly, I would say that most veterans are probably managing quite well relative to the three grams. If you look at medical marijuana use across the industry, it probably averages one and a bit more grams per day. Certainly there are folks, when you look at the extent and severity of PTSD that a veteran has gone through, most of us can’t imagine the experiences they have gone through. Certainly those are the folks who often need a higher dosage. Effectively, we facilitate that process in terms of the required assessment. We make the determination that they are a good candidate for a second-level assessment. We set up a session with a psychiatrist who validates their diagnosis and how they are performing at the current level.
The prescription has already been defined previously at an appropriate dosage. The difference here is that if the prescription was for 5 grams, Veterans Affairs is only funding three. For some folks cannabis, is not inexpensive, if it averages out to $10 per gram or so in the general market. For some veterans that extra simply isn’t possible for them. The psychiatrist is validating that it is an appropriate prescription based on their diagnosis, and is then indicating to Veterans Affairs Canada that in our view it is medically necessary for that person. Veterans Affairs Canada would ultimately make that determination on the second-level assessment. If it is successful, their coverage is extended beyond the three grams.
Mr. McGee: I think the cutbacks to three grams is an appropriate step to have taken. Initially, it presented some challenges to some veterans in accessing their medicine. But, as everything has shaken out, we have second-level assessments available to those veterans who need them. Again, we are grateful to Veterans Affairs Canada for offering that coverage.
I don’t ever want you to think we are encouraging people to get second-level assessments to get coverage above three grams. The only time would a second-level assessment would be offered is if that person is already prescribed and utilizing more than 3 grams. Then the second-level assessment would come over top of that to help them obtain that coverage for additional medication.
Senator McIntyre: What portion of your patients require more than 3 grams of cannabis per day?
Mr. McGee: Of the approximately 2,300 veterans we have, I believe 500 to 600 have used second-level assessments.
Senator McIntyre: How many grams per day?
Mr. McGee: That would typically range between 3 and 10 grams a day. Often patients who are using more medical cannabis have compounded conditions, so they have PTSD as well as having suffered a blast injury and so they have chronic pain issues as well. They are often consuming that medication in the form of oils or edibles for pain treatment.
Senator McIntyre: Thank you.
Senator Richards: I have my notes here, but I can’t read them. How many joints is 3 grams?
Mr. McGee: That would be approximately five or six joints.
Senator Richards: You are doing research in data with these veterans, and veterans aren’t the only ones that suffer from PTSD. A lot of the people do.
Mr. McGee: Absolutely.
Senator Richards: I came from an area that had a lot of drugs and a lot of drug use as kids that went on around me. I saw it and I saw that there was a lot of damage done. We all know that.
Mr. Kroon: Yes.
Senator Richards: As far as the research goes, if a person is self-medicating outside the Veterans Affairs facilities with other marijuana, how does that figure into it? Can you know that? Can you know if a person is doing that? I am sure someone will be doing that and it might screw up the data and the research.
How do you keep tabs on that, or do you? Do you know anything about that?
Mr. Kroon: Let me start. Part of our intake process, which is a fairly fundamental aspect of a second-level assessment as well, is to understand that. We ask those questions, not only in terms of what other prescription drugs people are using but with alcohol consumption and other illegal drugs. Before they start cannabinoid therapy, which can be a way of coping unfortunately. Certainly that factors into our advice for people.
Again I made the comment that unfortunately, sometimes the media talks about a gateway drug, but we think it is an exit medicine from a harm reduction perspective. It is a very effective way of transitioning away from some of those dependencies into a much healthier circumstance.
It is important and fundamental to the second-level assessment process in particular, since you were asking about it, that we understand everything that is going on. Obviously if you are talking about self-medicating in terms of cannabis use outside of the medical piece, we try to understand our clients as best we can. In terms of our message to the general public, it is very hit and miss in terms of whether you are trying to self-medicate. It is strongly recommended to go through a proper coaching process around it.
Mr. McGee: I think it is a great question. That is one of the challenges we face. We screen for drug-seeking behaviour but if we discovery through that screening that a patient is using illicit substances or other substances outside of a medical regime, is that a reason not to prescribe? Potentially, this prescription can help them lower the use of those drugs. It is a double-edged sword, I think. We monitor it closely. We do turn patients away and cancel authorizations if we discover that people are accessing illicit drugs or cannabis outside the programs. We are cognizant of that, our nurses and people at our clinics. We take action if we see things that are inappropriate; we absolutely do.
Senator Richards: I am not trying to be self-righteous about this. I am asking the question for the help of the veteran himself or herself. That is why I am asking.
Mr. McGee: That is why we invested not only in our software but in our not-for-profit, the Post Traumatic Growth Association. There are eight spokes of wellness that is based on. They are sleep, diets, exercise, financial health, relationships, and all these different things that veterans need to find balance in their lives. That is why we believe cannabis is a great treatment and treats those conditions, but it will be in these peer support groups and in communication with their peers that things like these issues will be identified and guys will get the right direction.
I think we would all agree that the people you associate with and the actions and intentions of those people will have a lot of influence where you go and what paths you take. We try to have a strong, positive culture in these peer support groups and encourage people down the right path.
That is a very important component and another place where we would like to see more funding and support, namely around programs where you have accredited facilitators and an approved program. There should be some funding available. We fund those at great expense because we know how critical it is. It would be great to have support for these programs that we know work and pair well with the investment that Veterans Affairs Canada is making in cannabis.
Mr. Kroon: Your question reminded me of one point that I think is interesting in the sense that we see ourselves as part of a local holistic approach to the patient. Whether you are talking about illicit drugs or other prescription drugs, I mentioned our overall process before. Our preferred model is a referral from a physician. I want to clarify that. In our process, we also then communicate back to the referring physician to indicate this is what we are doing with the patient.
Frankly, we would love — and hopefully legalization begins to change the attitude of more and more doctors — to be part of a health team working on a patient and share information with their referring physician in terms of what we are seeing and what we are recommending so that we can work on it together.
I spend a lot of time with different health care companies. One of the biggest issues in terms of health care is the silos that occur within the system. From our perspective, we don’t want to be a silo. We want to be integrated within the circle of care around that patient. We want to be part of that.
Mr. McGee: We need to involve the care teams of these patients. You are perhaps not seeing the reduction in pharmaceutical use that you would like to see in correlation with the cannabis use. A lot of that has to do with the silos, as Alex said.
A lot of veterans can’t go to their prescribers or treating physicians and tell them they are using cannabis, because they will not deal with them. Until we almost mandate that they drop the stigma and work cooperatively with a cannabinoid therapy specialist, then the care team is working collectively to either reduce pharmaceutical or reduce cannabis use, but which has a mandate to reduce drug use, period.
Senator Richards: Thank you.
Mr. Kroon: No problem. Thank you.
Senator McIntyre: Thank you for your presentations. I think the key is medical follow-up. Unlike veterans, the problem with recreational marijuana users is that they don’t have a follow-up. That’s the reason they get themselves into trouble and develop physical and mental ailments. Thank you for your presentations.
Mr. Kroon: Thank you.
The Acting Chair: On behalf of the Subcommittee on Veterans Affairs, Mr. McGee, let me first thank you for your service, on behalf of all Canadians. I want to thank you both for your presentations. This has been a very interesting hour. We are deeply appreciative of your presence here. Thank you.
Mr. McGee: Thank you for the opportunity.
Mr. Kroon: Thank you so much.
(The committee adjourned.)